<%@ page language="java" contentType="text/html; charset=UTF-8"
	pageEncoding="UTF-8"%>

<%@ taglib uri="http://tiles.apache.org/tags-tiles" prefix="tiles"%>
<%@ taglib uri="http://www.springframework.org/tags" prefix="spring"%>

<tiles:insertDefinition name="defaultTemplate">
<tiles:putAttribute name="pageheader">
      <h2><i class="fa fa-home"></i>Hospital<span>hospital details</span></h2>
</tiles:putAttribute>
	<tiles:putAttribute name="body">
		<div class="panel panel-default">
			<div class="panel-heading">
				<h4 class="panel-title">Hospital  โรงพยาบาล</h4>
			</div>
			<div class="panel-body panel-body-nopadding">
				<div class="form-horizontal form-bordered">
					<div class="form-group">
						<div class="col-xs-12">
							<blockquote>
								<p>Information of hospital</p>
							</blockquote>
						</div>
						<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right ">
												Hospital Code *</label>
											<div class=" col-xs-4 ">
												<div class="input-group">
													<input type="text" class="form-control input-sm"> <span
														class="input-group-btn"> <span
														class="btn btn-success btn-sm" style="margin-top: 3px;">
															<i class="fa fa-search"></i>
													</span>
													</span>
												</div>
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right ">
												Description Thai</label>
											<div class=" col-xs-6 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 ">
												Description ENG</label>
											<div class=" col-xs-6 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 ">
												Company Name</label>
											<div class=" col-xs-6 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0">
												Tax No.</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pr-0">
												Authorize Name</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
											<label class="col-xs-2 control-label text-right pr-0">
												Authorize Position</label>
											<div class=" col-xs-4 ">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
							</div>
						</div><!-- end row -->
					</div><!-- end form-group -->
					<div class="form-group">
						<div class="col-xs-12">
							<blockquote>
								<p>Address of hospital</p>
							</blockquote>
						</div>
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Building Name</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
											<label class="col-xs-2 control-label text-right pr-0">
												Floor</label>
											<div class=" col-xs-2 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0 ">
												Address No.</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
											<label class="col-xs-2 control-label text-right pr-0">
												Moo</label>
											<div class=" col-xs-2 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Soi</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pl-0 pr-0 ">
												Road</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Sub District</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pl-0 pr-0 ">
												District</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Province</label>
											<div class=" col-xs-8 pr-0">
												<select class="form-control input-sm">
													<option>------  Select Province ------</option>
												</select>
											</div>
											
										</div>
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												PostCode</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
					</div><!-- end form-group -->
					<div class="form-group">
						<div class="col-xs-12">
							<blockquote>
								<p>Bank</p>
							</blockquote>
						</div>
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 pr-0">
												Accont No.</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
											<label class="col-xs-2 control-label text-right pr-0">
												Bank Code</label>
											<div class="col-xs-3 pr-0 ">
												<div class="input-group ">
													<input type="text" class="form-control input-sm "> <span
														class="input-group-btn"> <span
														class="btn btn-success btn-sm" style="margin-top: 3px;">
															<i class="fa fa-search"></i>
													</span>
													</span>
												</div>
											</div>
											<div class="col-xs-7 pl-0">
												<input type="text" class="form-control  input-sm " />
											</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
											<label class="col-xs-2 control-label text-right pr-0 ">
												Branch Code</label>
											<div class="col-xs-3 pr-0 ">
												<div class="input-group ">
													<input type="text" class="form-control input-sm "> <span
														class="input-group-btn"> <span
														class="btn btn-success btn-sm" style="margin-top: 3px;">
															<i class="fa fa-search"></i>
													</span>
													</span>
												</div>
											</div>
											<div class="col-xs-7 pl-0">
												<input type="text" class="form-control  input-sm " />
											</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 lg-text pr-0">
												(Citi Bank) Party Name</label>
											<div class=" col-xs-4 pr-0 posit-lg-text">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 pr-0">
												(Citi Bank) Party ID</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
										<div class="col-xs-12 ">
											<label class="col-xs-2 control-label text-right pl-0 pr-0">
												(Citi Bank) Account</label>
											<div class=" col-xs-4 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
								</div>
							</div>
						</div><!-- end row -->
					</div>
					<!-- end form-group -->
					<div class="form-group">
							<blockquote>
								<p>Condition of medical fee</p>
							</blockquote>
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-12">
											<div class="col-xs-6 ">
												<label class="col-xs-4 control-label text-right pr-0">
													Tax End Month</label>
												<div class=" col-xs-8 ">
													<select class="form-control input-sm">
														<option>------ Select Month ------</option>
													</select>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 " style="height: 33px;">
											<label class="col-xs-4 control-label  xl-text">
												Guarantee Include Extar </label>
											<div class=" col-xs-7 posit-xl-text ">
												<div class="col-xs-5" style="padding-left: 9px;">
													<input type="radio" id="yes" name="Include_extra" value="1"
													checked="checked" /> <label class=" control-label">Yes</label>
												</div>
												<div class="col-xs-5" style="padding-left: 9px;">
													<input type="radio" id="no" name="Include_extra" value="0" />
													<label class="control-label">No</label>
												</div>
												
												
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Guarantee Day </label>
											<div class=" col-xs-7 " style="padding-left: 8px;">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="Guarantee" value="1"
														checked="checked" /> <label class=" control-label">VER</label>
												</div>
												<div class="col-xs-5" style="padding-left: 8px;">
													<input type="radio" id="no" name="Guarantee" value="0" /> <label
														class="control-label">INV</label>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 " style="height: 33px;">
											<label class="col-xs-4 control-label xl-text ">
												Guarantee All Alloc </label>
											<div class=" col-xs-7  posit-xl-text">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="All_Alloc" value="1"
													checked="checked" /> <label class=" control-label">Yes</label>
												</div>
												<div class="col-xs-5">
													<input type="radio" id="no" name="All_Alloc" value="0" />
												<label class="control-label">No</label>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												GL Account Code</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pl-0 pr-0 ">
												AC Account Code</label>
											<div class=" col-xs-8 pr-0">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 " style="height: 33px;">
											<label class="col-xs-5 control-label text-right pr-0 xxl-text">
												Sharing Account Code</label>
											<div class=" col-xs-8 pr-0 posit-xxl-text">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
										<div class="col-xs-6 " style="height: 33px;">
											<label class="col-xs-5 control-label text-right pl-0 pr-0 xxl-text ">
												Earning Account Code</label>
											<div class=" col-xs-8 pr-0 posit-xxl-text">
												<input type="text" class="form-control input-sm">
											</div>
										</div>
									</div>
								</div>
							</div>
						</div><!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Onward </label>
											<div class=" col-xs-7  ">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="Onward" value="1"
													checked="checked" /> <label class=" control-label">Yes</label>
												</div>
												<div class="col-xs-5">
													<input type="radio" id="no" name="Onward" value="0" />
													<label class="control-label">No</label>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Partial </label>
											<div class=" col-xs-7  ">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="Partial" value="1"
													checked="checked" /> <label class=" control-label">Yes</label>
												</div>
												<div class="col-xs-5">
													<input type="radio" id="no" name="Partial" value="0" />
													<label class="control-label">No</label>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Combine Bill </label>
											<div class=" col-xs-7  ">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="Combine_Bill" value="1"
													checked="checked" /> <label class=" control-label">Yes</label>
												</div>
												<div class="col-xs-5">
													<input type="radio" id="no" name="Combine_Bill" value="0" />
												<label class="control-label">No</label>
												</div>
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
						<div class="col-xs-12">
							<div class="col-xs-12">
								<div class="col-xs-12">
									<div class="col-xs-12">
										<div class="col-xs-6 ">
											<label class="col-xs-4 control-label text-right pr-0">
												Active </label>
											<div class=" col-xs-7  ">
												<div class="col-xs-5">
													<input type="radio" id="yes" name="ACTIVE" value="1"
													checked="checked" /> <label class=" control-label">Active</label>
												</div>
												<div class="col-xs-5">
													<input type="radio" id="no" name="ACTIVE" value="0" />
													<label class="control-label">Inactive</label>
												</div>	
											</div>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- end row -->
					</div><!-- end form-group -->
					

				</div>
				<div class="panel-footer">
					<div class="row">
						<div class="col-xs-6 col-xs-offset-9">
							<button class=" btn btn-success">
							<spring:message code="button.save" var="labelSubmit"/>
							${labelSubmit}
							</button>
							&nbsp;
							<button class=" btn btn-success">Reset</button>
							&nbsp;
							<button class=" btn btn-default">Close</button>
						</div>
					</div>
				</div>
				<!-- panel-footer -->
			</div>
		</div>

	</tiles:putAttribute>
</tiles:insertDefinition>
